Gordan Grahovac

Multiple Aspergillus brain abscesses in immuno-competent patient with severe cranio-facial trauma.

SummaryAspergillosis of the central nervous system (CNS) is a rare, but well described disease in immuno-competent patients. We present a 65-year-old patient who developed neuro-aspergillosis 10 months after severe cranio-facial trauma (Le Fort III). He was treated successfully with surgery including stereotactic drainage and, with Amphotericin B, Liposomal Amphotericin B, and Itraconazol.

Nightmare complication after lumbar disc surgery: cranial nontraumatic acute epidural hematoma.

Study Design. Case report. Objective. The nontraumatic cranial epidural hematoma is an extremely rare clinical entity and it commonly occurs in the presence of infectious diseases as complication of sinusitis, coagulopathy, vascular malformation of the dura, hemorrhagic tumor, in patients with sickle cell disease, systemic lupus erythematosus, after open heart surgery, and in patients on hemodialysis. Summary of Background Data. We reported a case of spontaneous epidural hematoma that occurred after herniated disc surgery. There was no history of preceding head trauma and patient medical history was unremarkable. To date, no report is found of cranial epidural hematoma after lumbar discectomy. Methods. A 58-year-old woman was operated because of a herniated disc at lumbar L3-L4 level and spinal stenosis. Bilateral L3-L4 interlaminectomies and L3-L4 discectomy were performed. Hemovac drain was placed in epidural space. Four hours after surgery, the patient developed left side weakness accompanied with nausea, vomiting, and severe headache. Urgent computed tomography of the head showed acute cranial epidural hematoma and the patient underwent emergent surgery. There was no evidence of trauma of the scalp or any other anatomical abnormality. Control computed tomography 14 hours after evacuation of the hematoma showed new extradural hematoma at the site of the previous one. Patient underwent second surgery. Results. Nine days after operation of the spine, patient recovered completely with no neurological deficit, but the cerebrospinal fluid showed at the place of spinal wound. Patient was operated once more and a minor dural tear was revealed, which was repaired. The patient was discharged on ninth postoperative and she recovered completely. Conclusion. There have been described rare cases of spontaneous subdural, intracerebral, and intracerebellar hematoma caused by intracranial hypotension, but this is the first described case of spontaneous cranial epidural hematoma after lumbar disc surgery caused by intracranial hypotension.

The effect of vagus nerve stimulation on migraine in patient with intractable epilepsy: case report.

A 42-year-old female had a long history of partial complex seizures dating from the age of 13. She was treated with the following anti-epileptic drugs (AEDs): primidone and phenytoin. In 2003, she had stopped AED treatments voluntarily due to ineffective medical therapy, and shortly after she was admitted again because of convulsive epileptic status. By 2003, she was experiencing six or seven seizures monthly. Magnetic resonance imaging (MRI) demonstrated a localized atrophy of the left middle frontal gyrus with a subcortical area of encephalomalacia. Electroencephalography (EEG) disclosed left fronto-centrotemporal interictal epileptiform discharges (IED) with diffuse paroxysmal dysrhythmic changes and elements of slow spikewave complexes. Single photon emission computed tomography (SPECT) showed an area of hypoperfusion in the left frontal area. In 2008, she experienced ten partial seizures per month, and by that time, the following AEDs failed for the patient: primidone, phenytoin, carbamazepine, lamotrigine, oxcarbazepine, vigabatrin, and gabapentin. She was evaluated for 14 days by video EEG (V-EEG) monitoring, which confirmed that the origin of the seizures was from the left frontal region. The patient also experienced typical common migraine attacks since puberty, with two or three episodes of migraine attacks per week, which were resistant to acute treatment. Migraines were characterized by unilateral pulsating headaches with photophobia followed by nausea and vomiting. Scintillating scotoma preceded attacks. These migraine attacks were not related to the epileptic seizures. The average intensity of headache on visual analogue scale (VAS) was eight to nine and the migraine disability assessment score (MIDAS) was about 50. In 2008, the patient refused grid electrode placement and possible neocortical resection. In 2009, she was offered VNS (NCP; Cyberonics, Webster, TX, USA) implantation. VNS was implanted in May, 2009. VNS was turned on seven days after surgery, and parameters were 0.25 mA, 30 Hz, 500 ls, with an ‘on’ time of 30 s every 5 min. These settings were well tolerated by the patient. After this implantation, the patient was discharged with these AEDs: oxcarbazepine (2,400 mg), vigabatrin (1,500 mg), and gabapentin (2,400 mg). Six months after the surgery, the VNS settings were corrected to 1.75 mA, 30 Hz, 500 ls, and ‘on’ time of 30 s every 5 min. S. Basic D. Sporis D. Chudy G. Grahovac (&) B. Nevajda Department of Neurosurgery, Clinical Hospital Dubrava, Av. Gojka Suska 6, 10000 Zagreb, Croatia e-mail: ggrahov@mef.hr

Primary diffuse meningeal melanomatosis.

Primary diffuse meningeal melanomatosis can clinically mimic a wide variety of other conditions, including lymphoma, leukemia, neurosarcoidosis, metastatic carcinoma, acute disseminated encephalomyelitis, subacute meningitis, viral encephalitis, and idiopathic hypertrophic cranial pachymeningitis. We report on a young patient with primary diffuse meningeal melanomatosis who presented with papilledema, flaccid paraparesis, and cognitive impairment. The importance of imaging of the whole central nervous system, cerebrospinal fluid analysis, and pathohistological examination is emphasized in making the appropriate diagnosis.

Charcot shoulder caused by Chiari type I malformation with syringomyelia with six-year follow-up.

ZusammenfassungWir berichten radiologische und klinische Details einer Patientin mit einer durch Syringomyelie und Chiari Typ 1 Malformation ausgelösten neuropathischen Gelenkserkrankung der Schulter. Neuropathische Gelenke sind 1868 erstmals von Charcot beschrieben worden. In der Folge wurden sie bei vielen Arten von peripheren und zentralen Nervenerkrankungen beobachtet. Es gibt viele Gründe für eine Syringomyelie – einer davon ist die Chiari Typ 1 Malformation. Schulter und Ellbogen sind am häufigsten von der Syringomyelie-induzierten Neuropathie befallen. Unsere Patientin wurde 6 Jahre seit der Diagnosestellung einer neuropathischen Arthropathie verbunden mit einer durch Chiari Typ 1 Malformation induzierten Syringomyelie kontrolliert. Nach der Operation zeigte sie keinerlei Progression der Erkrankung.SummaryWe are presenting a case report of neuropathic arthropathy of the shoulder secondary to a syringomyelia and Chiari type I malformation, with detailed clinical and radiological findings. Neuropathic joints were first described in 1868 by Charcot, and subsequently were described in many types of peripheral diseases and central neuron diseases. There are many causes of syringomyelia, and one of the causes of this disease is a Chiari type I malformation. Subsequently, shoulders and elbows are most commonly affected by syringomyelia-induced neuropathy. Our patient was observed for six years after being diagnosed with neuropathic arthropathy and syringomyelia caused by Chiari and did not show any disease progression after their surgery.

Solid hemangioblastoma of vestibular nerve mimicking vestibular schwannoma.

We report a case of solid hemangioblastoma originating from the vestibulocochlear nerve that was misdiagnosed with vestibular schwannoma. Most common cerebellopontine angle (CPA) neoplasms are vestibular schwannoma and accounting more of 90 % of neoplasms in CPA [1]. Central nervous system hemangioblastoma (HMBs) are a benign hypervascular neoplasm that constitutes 1–2.5 % of all intracranial tumors in the posterior fossa [2]. Hemangioblastomas commonly have a classical cystic appearance with a vascular mural nodule [2]. A 75-year-old woman has been treated for hemangioblastoma of the left cerebellar hemisphere in 1986 and in 1989. The contrast-enhanced computed tomography (CT) revealed cyst with mural nodule of the left cerebellar hemisphere. In 2013 she was hospitalized because of sudden right deafness and cerebellar ataxia. CT and magnetic resonance imaging (MRI) of the brain demonstrated a 2.9 9 2.6-cm solid tumor in the right cerebellopontine angle that was vividly enhancing and filling the inner auditory channel that was most consistent with vestibular schwannoma (Fig. 1). The patient underwent resection of the lesion via a right suboccipital retrosigmoid approach. Highly vascular solid mass was revealed and removed in piecemeal fashion. The procedure was complicated with profuse bleeding from the tumor. The bleeding was controlled by bipolar coagulation, Surgicel (Ethicon, USA) and Surgiflo with thrombin (Ethicon, USA). The postoperative course was uneventful. Pathologic evaluation revealed a highly vascular neoplasm composed of mildly atypical stromal cells with hyperchromatic nuclei and variable amounts of cytoplasm (Fig. 2). Large number of cells displayed copious amounts of foamy, lipidized cytoplasm. A final diagnosis of hemangioblastoma was made. The patient clinical workup included detailed clinical history, ophthalmoscopy examination, MRI of the brain and spine and CT of the abdomen, and plasma chromogranin A for Von Hippel–Lindau (VHL) syndrome was negative. Hemangioblastoma are benign highly vascular lesions that most commonly arise in the cerebellum. These tumors can remain asymptomatic for long time due to slow growth. 25 % of the HMBs occur in patients with autosomal-dominant disease called VHL disease [3]. The HMBs of the cerebellum have classical appearance, reddish to brown mural nodule with single or multiple cysts. In cases when the HMBs occurs in spinal cord or cranial and peripheral nerves, they can have solid MRI appearance as presented in our case. Hemangioblastoma seldom occur within CPA [4–7]. Majority of CPA hemangioblastoma originates from cerebellar tissue. Only in three cases the origin of the HMBs was from vestibulocochlear nerve, as was in our case [4, 6]. In the case by Ferroli et al. [5] the tumor was only visualized during surgical removal of cerebellar HMBs in the patient with known VHL disease. Hemangioblastoma and schwannoma of the CPA are characterized by isoto hypointensity on T1-weighted & Gordan Grahovac ggrahov@mef.hr

Simultaneous conus medullaris ependymoma and cerebellar astrocytoma in the same patient.

Multiple primary tumors in the central nervous system of different histological cell types are uncommon. We report a patient who had pilocytic astrocytoma in the cerebellum and ependymoma in the cauda equina region, occurring simultaneously. The suggested mechanism of this association is that primitive multipotent cells might have been displaced in the different CNS areas and developed in different tumor cells. Multiplicity of primary CNS tumors should be considered in certain occasions, when clinical symptoms and signs are pointing in that direction.

Effect of anular closure on disk height maintenance and reoperated recurrent herniation following lumbar diskectomy: two-year data.

OBJECTIVE To assess the potential benefits of disk reherniation reduction and disk height maintenance in limited diskectomy combined with the implantation of the anular closure device. SUMMARY AND BACKGROUND DATA Postoperative disk height loss is apparent in most patients undergoing lumbar diskectomy for herniated nucleus pulposus. Less favorable patient outcomes are associated with significant loss in disk height that can occur after aggressive disk tissue removal. More conservative disk removals, however, are often burdened by the increased risk of recurrent disk herniation. METHODS Two prospective single-arm studies on patients treated with limited diskectomy and an anular closure device were conducted. Outcome measures included disk height maintenance relative to preoperative values, Oswestry Disability Index, back pain, leg pain, and complications such as reherniations. Patients were evaluated preoperatively and postoperatively at 6 weeks and at 3-, 6-, 12-, and 24-month time points. RESULTS A total of 75 patients were included in this cohort consisting of 40 men and 35 women with an average age of 40 years. Disk height maintenance within the group overall was 90% at 24 months. Overall, 97% of the treated disks demonstrated disk height maintenance of at least 75% of preoperative levels at 12 months and 92% at 24 months. Disk height maintenance was correlated with less nucleus removal. Patient disability, back pain, and leg pain were significantly improved from preoperative levels at 6 weeks and maintained over the course of study. There was a single symptomatic reherniation requiring surgical intervention within this series. CONCLUSIONS Limited lumbar diskectomy combined with the use of an anular closure device provided very low rates of disk reherniation and exhibited excellent disk height maintenance and sustained disability, leg pain, and back pain improvement within a 24-month postoperative study period. As with prior diskectomy studies, disk height maintenance was correlated with lower nucleus removal, although recurrence was less than in prior reports of limited diskectomy. Anular closure may allow for achievement of both objectives.

Extracranial propagation of glioblastoma with extension to pterygomaxillar fossa

BackgroundGlioblastoma multiforme is a highly malignant primary brain tumor that shows marked local aggressiveness, but extracranial spread is not a common occurrence. We present an unusual case of recurrent glioblastoma in 54-year old male that spread through the scull base to the ethmoid and sphenoid sinuses, to the orbita, pterygomaxillar fossa, and to the neck.MethodsA 54-year old male underwent left temporal resection because of brain tumor of his left temporal lobe. Operation was followed by external beam radiation combined with temozolomide. The tumor recurred eight months after first surgery. The patient developed swelling of left temporal region, difficult swallowing and headache. MRI of head showed recurrent tumor, which invaded orbita, ethmoid and sphenoid sinuses, nasal cavity, pterygomaxillar fossa.ResultsThe patient died ten months after initial diagnosis of glioblastoma multiforme, and two months after his second operation.ConclusionsThe aggressive surgical operation helped to downsize the tumor mass as much as possible, but did not prolonged significantly the life or improved the life quality of the patient. The current literature is reviewed, and the diagnostic approaches as well as therapeutic options are discussed.

Hemangiopericytoma arising at the site of the benign meningeoma 7 years after surgery.

Sir, In 1999, a 60-year-old male patient presented with depression, cognitive decline and left-sided weakness. Neurological examination revealed disorientation in time and place, left-sided hemiparesis with brisk reflexes, positive Babinski sign, and central facial paresis. Brain computed tomography (CT) revealed a temporoparietal solid cystic mass (4.5 9 3.3 cm) with perifocal edema, and compression of the right temporal lobe (Fig. 1). Post-contrast scans showed strong enhancement. Pre-operatively, the patient underwent pancerebral digital subtraction angiography, which showed tumor vascularization from the left maxillary artery. Frontotemporal craniotomy with total tumor resection was performed. The dural defect was closed with dural substitute (Liodura, Braun). The histopathologic diagnosis was meningioma (Fig. 2). Postoperative CT scan revealed no evidence of residual tumor and the post-operative course was uneventful. The patient was consequently followed up until 2005, with no evidence of disease recurrence and neurological status recovered completely. In 2006, the patient had an attack of general weakness with profuse sweating. Physical examination revealed only discrete left central facial paresis. Brain CT revealed a temporoparietal mass (4.5 9 4.2 cm) at the same site as before the first surgery (Fig. 3). Frontotemporal recraniotomy was performed to reveal a pinky, highly vascular mass. Intraoperatively, the left sphenoid ridge was seen to be infiltrated with the tumor. On histopathology, it was found to be a highly cellular and mitotically active tumor, with high density vascular mesh and tumor cells around it. Immunohistochemistry showed cells staining positive for CD34 and negative for CD31 and EMA (Fig. 4). These findings were consistent with hemangiopericytoma. Postoperative brain CT showed no evidence of residual tumor and the patient was referred to the oncologist for further irradiation treatment. Hemangiopericytoma is an uncommon neoplasm, usually occurring in the musculoskeletal system or skin, and arising from Zimmerman pericytes around capillaries and post-capillary venules. Hemangiopericytoma arising in the central nervous system is very rare; meningeal hemangiopericytomas account for approximately 2.5% of all meningeal tumors and 1% of all intracranial tumors [1, 2]. It is considered to be a mesenchymal and non-meningeal tumor according to the latest World Health Organization classification [3]. In our case, hemangiopericytoma developed at the site of a benign meningioma totally removed 7 years before. Hirose et al. describe a case of hemangiopericytoma arising at the site of fascial dural graft derived from the femoral quadriceps muscle 13 years after total removal of a benign meningioma. They concluded that the most probable origin of this tumor was the dural scar tissue of the graft and considered it to be a scar tumor [4]. In that case as well as in our patient, the recurrent tumor was misdiagnosed as recurrent meningioma. Our case appears to be the second case of hemangiopericytoma development at the site of T. Marinović G. Grahovac Department of Neurosurgery, University Hospital ‘‘Dubrava’’, Zagreb, Croatia